CHHS18/099

Canberra Hospital and Health ServicesOperational Guideline Pre and Post-Operative Care of the Adult Special Needs Patient in Day Surgery Unit (DSU)/Day of Surgery Admission (DOSA)Contents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Surgical Bookings/Pre-admission Clinic..................................................................3

Section 2 – Emergency Admission.............................................................................................4

Section 3 – Pre-operative Care..................................................................................................4

Section 4 – Post-Operative Care...............................................................................................5

Implementation........................................................................................................................ 6

Related Policies, Procedures, Guidelines and Legislation.........................................................7

References................................................................................................................................ 8

Definition of Terms...................................................................................................................8

Search Terms............................................................................................................................ 8

Doc Number Version Issued Review Date Area Responsible PageCHHS18/099 1 15/03/2018 01/04/2022 Surgery and Oral

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CHHS18/099

Guideline Statement

Patients identified as ‘Special Needs’ patients may require complex planning and resource allocation. This will need to be coordinated utilising a multidisciplinary approach to ensure a safe journey through the Peri-operative Unit.

BackgroundThe term ‘Special Needs’ is applied to an array of diagnoses. People with special needs may have a wide range of physical and intellectual disabilities and medical conditions. These conditions can range from mild learning disabilities to profound cognitive impairment, developmental delays that remain entrenched, occasional panic attacks or serious emotional problems. To ensure a positive patient experience during an elective surgical admission, the patient’s individual and detailed information needs to be communicated to all stakeholders. The stakeholders, need to develop and implement plans from this information to deliver high quality and appropriate care.

Key ObjectiveTo ensure a safe and high standard of care for the patient with ‘Special Needs’, throughout the patient’s surgical journey.

Alerts Patients with special needs can be unpredictable in their behaviour and this can be

amplified in an unfamiliar environment and with unfamiliar staff. New and unfamiliar environments can increase anxiety and stress for the Special Needs patient causing distress, agitation and associated behaviours.

All nursing, medical and support staff associated with providing care and assistance to the special needs patient, need to be mindful of non-compliance with activities associated with the surgical process. If any activity causes or creates distress in the patient, the activity must be ceased. Consultation with the carer/family must occur throughout the surgical journey. Documentation within the patient’s notes is required for the rationale behind any changes in process.

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Scope

This operational guideline applies to adult patients (from 14 years old) who are identified as requiring special needs or considerations.

This operational guideline is specifically related to the care of these patients in Pre-Admission Clinic (PAC), Day Surgery Admissions- (DSA), Post Anaesthetic Care Unit – (PACU), Operating Rooms and Day of Surgery Admission patients – (DOSA).

This operation guideline applies to nursing, medical and support staff under the clinical governance of the Canberra Hospital and Health Service (CHHS) - Surgery and Oral Health:

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CHHS18/099

Registered Nurses Enrolled Nurses Medical Officers Students under direct supervision Wards Services staff

Stakeholders include: Assistant Director of Nursing (ADON) Surgical Bookings ADON Perioperative Unit Clinical Nurse Consultant (CNC) Extended Day Surgery Unit (EDSU) CNC PACU CNC Anaesthetics Theatre Patient Flows Anaesthetic Office Manager ( Anaesthetist Department) Surgical Booking Clerk Elective Surgery Liaison Nurses PAC Nurse Team

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Section 1 – Surgical Bookings/Pre-admission Clinic

1. The patient is booked on the Elective Surgery Waiting List according to their assigned clinical urgency category time-frame.

2. The PAC nursing staff will contact the patient and/or carers to assess and document any special needs on the Pre-Admission Special Needs Assessment Form.

3. This information is then utilised to formulate a plan to assist in coordinating care for the patient’s surgical journey in consultation with the Elective Surgery Liaison Nurse.

4. The PAC nurse will liaise with an Anaesthetist for the surgery regarding a proposed anaesthetic management plan. This plan may include the need for administration of pre-medication on the day of surgery.

5. PAC nursing staff will provide all stakeholders with a copy of the completed Pre-Admission Special Needs Assessment Form and developed management plan, if required, via email 7 days prior to proposed admission date.

6. PAC nurses will also send the most recent anaesthetic assessment, if available. Special attention should be paid to the pre-operative management plan within the assessment as this will outline specific individual requirements for the patient .

7. Patients are informed of their admission time by the PAC Nurse and any other special requirements as per their management plan.

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Section 2 – Emergency Admission

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1. If a special needs patient requires an emergency admission for a surgical procedure, the procedure will be booked onto the Emergency theatre list according to their assigned clinical urgency category time-frame.

2. Bed Management will allocate an appropriate bed location for the patient in consultation with the appropriate ADON and CNC.

3. The Nursing Resource Office in consultation with the appropriate ADON and the ward area CNC will allocate additional staff if required.

4. For an admission through the DSU admission unit, the same pre-operative care process should be followed as per the elective admission process Section 3- Pre-operative Care

5. For an admission into the ward areas, an individual plan of care will be required as per the patient’s needs and requirements in consultation with the patient’s carer.

6. The post-operative care process should be undertaken as per Section 4 Post-Operative Care.

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Section 3 – Pre-operative Care

1. An additional EDSU nursing staff member will be rostered and allocated by the EDSU CNC to care for the Special Needs patient.

2. The Pre-Admission Special Needs Assessment for the patient will be available for the allocated Special Needs Nurse. The Special Needs Nurse will familiarise themselves with the patient’s individual needs and requirements to prepare for their admission.

3. In preparation for the patient’s arrival, the allocated PACU bed bay will be prepared with: patient trolley/electric bed recliner theatre attire for both patient and carer vital sign equipment

4. The times for admission will be documented on the elective theatre list. The admission times for patients to present for theatre will be staggered if there are 2 or more special needs patients on the elective surgery list

5. The clerical admission for the patient will be attended at the DSU admissions with the patient’s carer. On completion of the clerical admission, the Special Needs Nurse will be notified by the clerical staff

6. The patient and family/carers will be escorted to the allocated and prepared PACU bed bay by the Special Needs Nurse

7. Assistance from the theatre wards person may be requested for additional support for patient care, mobilisation and transfer

8. If a lifter is required, a wards person will be notified and they will collect the lifter from ICU. The wards person will assist with the lifter and transferring of the patient on to an electric bed

9. If possible, the patient is to be changed into theatre attire with the assistance of their family member /carer and the Special Needs Nurse. Alternatively, if the patient is uncooperative and non-compliant, the patient can be transferred to theatre in their own clothes

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10. Positive patient identification is to be undertaken utilising the family/carer to identify the patient, if the patient is unable to do so. Allergy status is to be confirmed. An appropriate ID wrist band should be placed on the patient’s wrist

11. The Consent for the Procedure is required to be checked with the family/carer. Reconfirmation of the consent may be necessary, dependent upon type of surgery. (Not required for Dental patients, Emergency patients or Caesarean section patients)

12. The Pre-operative Theatre Checklist, baseline observations and pre-medication administration are to be attended and documented

13. The allocated family member/carer who will accompany the patient to theatre will need to change into theatre attire

14. The allocated Anaesthetist assigned to the Special Needs theatre list will assess and review the patient in the PACU bed bay. If necessary the Anaesthetist will order pre- medication

15. Continual care will be provided to the patient by the Special Needs Nurse in PACU until the patient’s transfer to theatre

16. Clinical Handover of the patient will occur between the Special Needs Nurse and the Anaesthetic Nurse prior to transfer to theatre

17. The patient is escorted to theatre with the patient’s carer and Anaesthetic Nurse. The patient can be taken to theatre either on a trolley or recliner chair, as per the patient’s individual requirements utilising the assistance of a wards person.

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Section 4 – Post-Operative Care

1. On transfer from the operating theatre to PACU, the patient will be cared for by the PACU staff as per the usual Post Anaesthetic Care protocol

2. When patient meets PACU discharge criteria, the patient’s care will be transferred to the appropriate unit If the patient is a DOSA patient:

o The patient will be allocated an appropriate bed location by bed management in consultation with the appropriate ADON and ward area CNC

o The patient will be transferred by the PACU Staff to the designated wardo PACU staff will clinically hand over the patient to the ward staff-according to the

CHHS guidelineso Nursing care will be delivered in collaboration with the patient’s carer’s and

family o Post-operative care will be delivered in accordance with the post-operative

orders and surgical team review. If the patient is a DSU patient, the patient will be clinically handed over to the Special

Needs Nurse for post-operative care until discharge:o The patient will remain in PACU unit for their duration of their DSU post-

operative careo Post-operative observations to be continued as per CCHS protocol, dependant on

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o Intravenous Cannula (IVC) can be removed if causing distress; otherwise the IVC should remain until time of discharge

o All care will be delivered in consultation and collaboration with the family/carer, including observation, nourishment and redressing into own clothes

o Observations to be attended as per post-operative policy- ½ hourly for 2 hourso The wards person can assist with any required transfers, lifts or mobilisation of

the patiento The patient will be discharged from PACU by the Special Needs Nurse as per the

Day Surgery Discharge assessment criteria into the care of the carer/family o The General Anaesthetic Fact Sheet will be given with full explained to the

family/carer. Follow up advice and any further post-operative instruction will be given to the family/carer, both verbally and written on the fact sheet. A copy of the operation report will be given to the family/carer for the patient’s GP

o Any discharge medications will be organised and given to the family/carer with explanation. Alternatively the family/carer can pick up discharge medications from the pharmacy

o Once all discharge information is given, the IVC has been removed and the patient is considered safe for discharge, the nurse and carer/family must sign the discharge summary prior to the patient leaving the unit

o The Special Needs Nurse is responsible for the completion of documentation relating to the care of the patient during this episode of care.

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Implementation

As a part of the ongoing education, all EDSU nursing staff are required to view the power-point ‘Care of the Special Needs patient’ which will be documented in the essential training spreadsheet for EDSU.

The Nursing staff orientation of EDSU will include a component for the Pre and Post-Operative Care of the ‘Special Needs Patient’.

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Related Policies, Procedures, Guidelines and Legislation

Policies Health Directorate Nursing and Midwifery Continuing Competence Policy CHHS Policy: Consent and Treatment Administration of Hospital Admissions and Discharges Policy CHHS Clinical Policy: Patient Identification and Procedure Matching Policy CHHS Clinical Policy: Medication Handling

Procedures CHHS Clinical Procedure: Admission Discharge-Adults, Pregnant Women and Neonates CHHS Clinical Procedure: Healthcare Associated Infections Clinical Procedure CHHS Clinical Procedure: Falls Prevention and Management CHHS Clinical Procedure: Clinical Handover Procedure CHHS Clinical procedure- Pressure Injury Prevention and Management: Adults, Children

and Neonates

Guidelines CHHS Clinical Guideline: Fasting Guidelines – Elective and Emergency Surgery

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011 Health Practitioner Regulation National Law (ACT) Act 2010 Health Records (Privacy and Access) Act 1997 Health Regulation (Maternal Health Information) Act 1998 Human Rights Act 2004 Privacy Act 1988 Children and Young Peoples Act 2008 Guardianship and Management of Property Act 1991 Medical Treatment (Health Directions) Act 2006 Mental Health Act 2015 Powers of Attorney Act 2006

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References

1. Centre for developmental Disability Studies for NSW Health. NSW Department of Health (2006).Health Care in People with Intellectual Disability.https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0016/231514/Health_Care_in_People_with_Intellectual_Disability_Guidelines.pdf . Downloaded August 2017

2. School of Health and Social Work, University of Hertfordshire (2017.) Understanding Intellectual Disability and Health. http://www.intellectualdisability.info/intellectual-disability . DownloadedAugust 2017

3. Mauro Terri, (2013). Children with Special Needs. About.com

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Definition of Terms

CNC -Clinical Nurse ConsultantADON -Assistant Director of NursingEDSU -Extended Day Surgery UnitDSU -Day Surgery UnitPACU -Post Anaesthetic Care UnitPAC -Pre Admission ClinicDOSA- Day of Surgery Admission

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Search Terms

Special Need, Pre and post-operative Care, Disability, Special Needs

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 14/03/2018 Complete Review Daniel Wood, A/g ED

SOHCHHS Policy Committee

This document supersedes the following: Document Number Document NameCHHS13/426 Pre and Post op Care of Special Needs Patients SOP

Doc Number Version Issued Review Date Area Responsible PageCHHS18/099 1 15/03/2018 01/04/2022 Surgery and Oral

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register